Mood disorders following traumatic brain injury

Mood Disorders in the Wake of Traumatic Brain Injury: A Systematic Review

Traumatic brain injury (TBI) frequently leads to a myriad of long-term consequences, among which mood disorders present a significant challenge. This systematic review delves into the complex interplay between TBI and subsequent mood disorders, focusing on research studies conducted over the past decade. Encompassing an age range from 12 years old to older adults (60+ years), our review aims to elucidate the epidemiological patterns, neurobiological mechanisms, and psychosocial factors that contribute to the development of mood disorders following TBI. By synthesizing the current literature, we seek to uncover the prevalence and clinical implications of this often-under-recognized comorbidity. For the quality appraisal of the reviewed articles, the Newcastle-Ottawa risk-of-bias tool and Scale for the Assessment of Narrative Review Articles (SANRA) checklist were employed. Ultimately, this review endeavors to provide a comprehensive understanding of the intricate relationship between TBI and mood disorders, offering insights crucial for improved management and intervention strategies in affected individuals.

Behavioral deficits after mild traumatic brain injury by fluid percussion in rats

Mild traumatic brain injury (TBI) can lead to various disorders, encompassing cognitive and psychiatric complications. While pre-clinical studies have long investigated behavioral alterations, the fluid percussion injury (FPI) model still lacks a comprehensive behavioral battery that includes psychiatric-like disorders. To address this gap, we conducted multiple behavioral tasks over two months in adult male Wistar rats, focusing on mild FPI. Statistical analyses revealed that both naive and sham animals exhibited an increase in sweet liquid consumption over time. In contrast, the TBI group did not show any temporal changes, although mild FPI did induce a statistically significant decrease in sucrose consumption compared to control groups during the chronic phase. Additionally, social interaction tasks indicated reduced contact time in TBI animals. The elevated plus maze task demonstrated an increase in open-arm exploration following fluid percussion. Nonetheless, no significant differences were observed in the acute and chronic phases for the forced swim and light-dark box tasks. Evaluation of three distinct memory tasks in the chronic phase revealed that mild FPI led to long-term memory deficits, as assessed by the object recognition task, while the surgical procedure itself resulted in short-term spatial memory deficits, as evaluated by the Y-maze task. Conversely, working memory remained unaffected in the water maze task. Collectively, these findings provide a nuanced characterization of behavioral deficits induced by mild FPI.

Mania Following Traumatic Brain Injury: A Systematic Review

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide. Mania is an uncommon, but debilitating, psychiatric occurrence following TBI. The literature on mania following TBI is largely limited to case reports and case series. In the present review, the investigators describe the clinical, diagnostic, and treatment characteristics of mania following TBI.

METHODS

A systematic search of MEDLINE, EMBASE, and PsycINFO was conducted for English-language studies published from 1980 to July 15, 2021. The included studies provided the required individual primary data and sufficient information on clinical presentation or treatment of manic symptoms. Studies with patients who reported a history of mania or bipolar disorder prior to TBI and studies with patients who sustained TBI before adulthood were excluded.

RESULTS

Forty-one studies were included, which reported information for 50 patients (the mean±SD age at mania onset was 39.1±14.3 years). Patients were more frequently male, aged <50 years, and without a personal or family history of psychiatric disorders. Although 74% of patients reported mania developing within 1 year following TBI, latencies of up to 31 years were observed. Illness trajectory varied from a single manic episode to recurrent mood episodes. Rapid cycling was reported in six patients. Mood stabilizers and antipsychotics were most frequently used to improve symptoms.

CONCLUSIONS

Heterogeneity of lesion locations and coexisting vulnerabilities make causality difficult to establish. Valproate or a second-generation antipsychotic, such as olanzapine or quetiapine, may be considered first-line therapy in the absence of high-level evidence for a more preferred treatment. Early escalation to combined therapy (mood stabilizer and second-generation antipsychotic) is recommended to control symptoms and prevent recurrence. Larger prospective studies and randomized controlled trials are needed to refine diagnostic criteria and provide definitive treatment recommendations.

Culturally Appropriate Assessment of Depression and Anxiety in Older Torres Strait Islanders: Limitations and Recommendations

OBJECTIVES

The aim of the study was to assess the prevalence of anxiety and depression in older Aboriginal and Torres Strait Islander adults.

METHODS

A modified version of the PHQ-9 (KICA-dep) and the Geriatric Anxiety Inventory (GAI) were administered as part of a wider dementia prevalence study conducted in the Torres Strait. Results were compared to diagnoses obtained on Geriatric review to evaluate their applicability in the region.

RESULTS

A total of 236 participants completed the KICA-dep and 184 completed the GAI short form. Of these, 10.6% were identified with depression and 15.8% with anxiety. Some participants found questions about suicide ideation and self-harm offensive and others had difficulty understanding concepts on the GAI. The KICA-dep performed poorly in comparison to diagnosis on geriatric clinical review, so results are unlikely to reflect the true prevalence of depression in the region.

CONCLUSIONS

Further research is required to explore the underlying dimensions of depression and anxiety and terminology used to express mood symptoms in the Torres Strait.

CLINICAL IMPLICATIONS

• Current mental health screening tools are not applicable for the Torres Strait• More work is required to determine how symptoms of depression and anxiety are expressed within Torres Strait communities.

Factors related to the quality and stability of partner relationships after traumatic brain injury: A systematic literature review

OBJECTIVE

The latest literature review on partner relationships following traumatic brain injury (TBI), conducted a decade ago, discussed solely quantitative work and noted significant knowledge gaps. The current review updates and expands on this work by providing an overview of the current state of knowledge on factors related to relationship quality and stability following TBI.

DATA SOURCES

CINAHL, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on April 23, 2020, for literature on factors associated with 1)relationship quality and 2)relationship stability following TBI.

STUDY SELECTION

English quantitative and qualitative studies investigating factors associated with relationship quality and/or stability following TBI were included. Two reviewers independently assessed eligibility. If consensus was not reached, a third reviewer's conclusion was decisive. Forty-three studies were included.

DATA EXTRACTION

Information regarding study objectives and characteristics, participant demographics, (in)dependent variables, and main findings was extracted. Study quality was rated using the JBI Checklist for Analytical Cross Sectional Studies and/or the CASP Checklist for Qualitative Research. Both were performed by the lead reviewer and checked by the second reviewer.

DATA SYNTHESIS

Thirty-eight factors related to relationship quality and/or stability were identified, covering injury characteristics (e.g., severity), body functions (e.g., personality changes), activities (e.g., communication), participation (e.g., social dependence), environment (e.g., children), and personal factors (e.g., coping strategies).

CONCLUSIONS

Relationship quality and stability following TBI are found to be related to a multitude of factors, including newly identified factors such as personality changes and dependence. Future research may wish to quantitatively investigate factors thus far only identified in qualitative research, explore possible positive effects of TBI on relationships, study the experiences of same-sex couples, and include the perspectives of both partners with and without the injury.

Treatment of Psychiatric Problems After Traumatic Brain Injury

Psychiatric sequelae of traumatic brain injury (TBI) can cause significant and often chronic impairment in functioning and quality of life; however, their phenomenological and mechanistic complexities continue to present significant treatment challenges. The clinical presentation is often an amalgam of syndromes and co-occurring symptoms that require a highly nuanced and systematic approach to treatment. Although few randomized controlled trials have tested treatments for psychiatric problems after TBI and the synthesis of results continues to be compromised by the heterogeneity of study populations, small samples, and differing inclusion criteria and outcome measures, an increasing body of literature supports evidence-based treatment strategies. We provide a narrative review of pharmacological, psychoeducational/behavioral, and neuromodulation treatments for psychiatric conditions in adults with TBI and discuss known or postulated mechanisms of action for these treatment approaches. Where data are available, we focus on randomized controlled trials and large case series in which a psychiatric condition provides both a selection criterion and a primary or secondary outcome. We conclude by proposing directions for future research, particularly the need for novel neuropharmacological, behavioral, and neurophysiological studies and pragmatic trials of multicomponent and adaptive models that will increase understanding of the mechanisms underlying post-TBI psychiatric disorders and accelerate dissemination and implementation of effective person-centered care.

Suicidal ideation after acute traumatic brain injury: A longitudinal actor-partner interdependence model of patients and caregivers in Latin America

PURPOSE/OBJECTIVE

Traumatic brain injury (TBI) is associated with depression, anxiety, and even suicidality in individuals with TBI and in caregivers. Moreover, emotional functioning in individuals with TBI is linked with caregiver functioning. However, no known studies to date have examined linkages in suicidal ideation in individuals with TBI and family caregivers. This is especially important in Latin America, where TBI rates are high, and where cultural norms influence family caregiving. This study examined associations among self-reported suicidal ideation in individuals with TBI and their primary caregivers over time in Mexico and Colombia. Research Method/Design: A total of 109 individuals and their primary caregivers completed measures during hospitalization for TBI and at 2- and 4-months posthospitalization. The primary outcome was Item 9 from the Spanish version of the Patient Health Questionnaire-9, assessing for thoughts of death or suicide in the previous 2 weeks.

RESULTS

Patients and caregivers reported high levels of suicidal ideation (18.3%-22.4% and 12.4%-15.7%, respectively) at each time point, and suicidal ideation at one time point strongly predicted ideation at the next. When patients endorsed suicidal ideation in the hospital, their caregivers tended to endorse suicidal ideation 2 months later. Although unaccounted for variables could be driving these relationships, they may also provide possible evidence of causal preponderance between patient and caregiver suicidal ideation post-TBI.

CONCLUSIONS/IMPLICATIONS

Clinicians and rehabilitation specialists can use these findings to inform suicide risk assessment by expanding these practices to caregivers of patients who endorsed suicidal ideation. Interventions after TBI should incorporate caregivers given this study showed significant interdependence of suicidality between patients and caregivers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Longitudinal Analyses of the Reciprocity of Depression and Anxiety after Traumatic Brain Injury and Its Clinical Implications

Depression and anxiety are common following traumatic brain injury (TBI). Understanding their prevalence and interplay within the first year after TBI with differing severities may improve patients' outcomes after TBI. Individuals with a clinical diagnosis of TBI recruited for the large European collaborative longitudinal study CENTER-TBI were screened for patient-reported major depression (MD) and generalized anxiety disorder (GAD) at three, six, and twelve months post-injury (N = 1683). Data were analyzed using autoregressive cross-lagged models. Sociodemographic, premorbid and injury-related factors were examined as risk factors. 14.1-15.5% of TBI patients reported moderate to severe MD at three to twelve months after TBI, 7.9-9.5% reported GAD. Depression and anxiety after TBI presented high within-domain persistency and cross-domain concurrent associations. MD at three months post-TBI had a significant impact on GAD at six months post-TBI, while both acted bidirectionally at six to twelve months post-TBI. Being more severely disabled, having experienced major extracranial injuries, an intensive care unit stay, and being female were risk factors for more severe MD and GAD. Major trauma and the level of consciousness after TBI were additionally associated with more severe MD, whereas being younger was related to more severe GAD. Individuals after TBI should be screened and treated for MD and GAD early on, as both psychiatric disturbances are highly persistent and bi-directional in their impact. More severely disabled patients are particularly vulnerable, and thus warrant timely screening and intensive follow-up treatment.

Electroconvulsive Therapy for Traumatic Brain Injury and Schizoaffective Disorder

Traumatic brain injury (TBI) is a source of disability and mortality with high rates of psychiatric disorders. Patients with comorbid TBI and psychiatric disorders may be safely treated with electroconvulsive therapy (ECT). In this case report, we present a 34-year-old man with the diagnosis of major neurocognitive disorder due to traumatic brain injury and schizoaffective disorder, bipolar type. He received an index course of 19 ECT treatments with clinical improvements in his psychosis, mood, and cognition. This case may support the utilization of ECT for patients with comorbid TBI and schizoaffective disorder.

Multipotential and systemic effects of traumatic brain injury

Traumatic brain injury (TBI) is one of the leading causes of disability and mortality of people at all ages. Biochemical, cellular and physiological events that occur during primary injury lead to a delayed and long-term secondary damage that can last from hours to years. Secondary brain injury causes tissue damage in the central nervous system and a subsequent strong and rapid inflammatory response that may lead to persistent inflammation. However, this inflammatory response is not limited to the brain. Inflammatory mediators are transferred from damaged brain tissue to the bloodstream and produce a systemic inflammatory response in peripheral organs, including the cardiovascular, pulmonary, gastrointestinal, renal and endocrine systems. Complications of TBI are associated with its multiple and systemic effects that should be considered in the treatment of TBI patients. Therefore, in this review, an attempt was made to examine the systemic effects of TBI in detail. It is hoped that this review will identify the mechanisms of injury and complications of TBI, and open a window for promising treatment in TBI complications.

[Mental disorders after acquired CNS damage]

Mental disorders are a frequent consequence of acquired central nervous damage. If not recognized and treated early, they have a negative impact on the course of neurological rehabilitation. This article deals with the diagnosis and treatment of mental disorders after acquired damage to the central nervous system.

Effects of neurological music therapy on behavioural and emotional recovery after traumatic brain injury: A randomized controlled cross-over trial

Traumatic brain injury (TBI) causes deficits in executive function (EF), as well as problems in behavioural and emotional self-regulation. Neurological music therapy may aid these aspects of recovery. We performed a cross-over randomized controlled trial where 40 persons with moderate-severe TBI received a 3-month neurological music therapy intervention (2 times/week, 60 min/session), either during the first (AB, n = 20) or second (BA, n = 20) half of a 6-month follow-up period. The evidence from this RCT previously demonstrated that music therapy enhanced general EF and set shifting. In the current study, outcome was assessed with self-report and caregiver-report questionnaires performed at baseline, 3-month, 6-month, and 18-month stages. The results showed that the self-reported Behavioural Regulation Index of the Behaviour Rating Inventory of Executive Function (BRIEF-A) improved more in the AB than BA group from baseline to 3-month stage and the effect was maintained in the 6-month follow-up. No changes in mood or quality of life questionnaires were observed. However, a qualitative content analysis of the feedback revealed that many participants experienced the intervention as helpful in terms of emotional well-being and activity. Our results suggest that music therapy has a positive effect on everyday behavioural regulation skills after TBI.

Executive (dys)function after traumatic brain injury: special considerations for behavioral pharmacology

Executive function is an umbrella term that includes cognitive processes such as decision-making, impulse control, attention, behavioral flexibility, and working memory. Each of these processes depends largely upon monoaminergic (dopaminergic, serotonergic, and noradrenergic) neurotransmission in the frontal cortex, striatum, and hippocampus, among other brain areas. Traumatic brain injury (TBI) induces disruptions in monoaminergic signaling along several steps in the neurotransmission process - synthesis, distribution, and breakdown - and in turn, produces long-lasting deficits in several executive function domains. Understanding how TBI alters monoamingeric neurotransmission and executive function will advance basic knowledge of the underlying principles that govern executive function and potentially further treatment of cognitive deficits following such injury. In this review, we examine the influence of TBI on the following measures of executive function - impulsivity, behavioral flexibility, and working memory. We also describe monoaminergic-systems changes following TBI. Given that TBI patients experience alterations in monoaminergic signaling following injury, they may represent a unique population with regard to pharmacotherapy. We conclude this review by discussing some considerations for pharmacotherapy in the field of TBI.

Depression and Depressive Symptoms in Pediatric Traumatic Brain Injury: A Scoping Review

OBJECTIVE

This scoping review aimed to summarize the existing knowledge base regarding depression and depressive symptoms in pediatric traumatic brain injury (TBI) and to identify gaps in the literature in an effort to guide future research.

METHODS

MEDLINE Ovid and PsycINFO Ovid databases were each searched by the authors using search terms intended to identify any original research study that examined depressive symptoms in children (ie, aged 0-18 years) with TBI.

RESULTS

A total of 14 published studies were included in the review. The studies included examined the prevalence of depression, risk factors associated with depression, and depression as a predictor of other TBI-related outcomes.

CONCLUSION

Existing research suggests that depressive symptoms are more common in a TBI population than in a healthy or orthopedically injured population. Injury-related factors such as lesions in the brain and the presence of pain, as well as noninjury factors such as older age at injury and low socioeconomic status, may be predictive of depressive symptoms. Depression is likely a secondary outcome of pediatric TBI rather than a direct result of the injury itself. Overall, a relative dearth of research exists on this topic; thus, the review concludes by proposing future research directions.

Affective, neurocognitive and psychosocial disorders associated with traumatic brain injury and post-traumatic epilepsy

Survivors of traumatic brain injury (TBI) often develop chronic neurological, neurocognitive, psychological, and psychosocial deficits that can have a profound impact on an individual's wellbeing and quality of life. TBI is also a common cause of acquired epilepsy, which is itself associated with significant behavioral morbidity. This review considers the clinical and preclinical evidence that post-traumatic epilepsy (PTE) acts as a 'second-hit' insult to worsen chronic behavioral outcomes for brain-injured patients, across the domains of emotional, cognitive, and psychosocial functioning. Surprisingly, few well-designed studies have specifically examined the relationship between seizures and behavioral outcomes after TBI. The complex mechanisms underlying these comorbidities remain incompletely understood, although many of the biological processes that precipitate seizure occurrence and epileptogenesis may also contribute to the development of chronic behavioral deficits. Further, the relationship between PTE and behavioral dysfunction is increasingly recognized to be a bidirectional one, whereby premorbid conditions are a risk factor for PTE. Clinical studies in this arena are often challenged by the confounding effects of anti-seizure medications, while preclinical studies have rarely examined an adequately extended time course to fully capture the time course of epilepsy development after a TBI. To drive the field forward towards improved treatment strategies, it is imperative that both seizures and neurobehavioral outcomes are assessed in parallel after TBI, both in patient populations and preclinical models.

Diffusion Tensor Imaging (DTI) Correlates of Self-Reported Sleep Quality and Depression Following Mild Traumatic Brain Injury

Background: Mild traumatic brain injuries (mTBIs) are a significant social, sport, and military health issue. In spite of advances in the clinical management of these injuries, the underlying pathophysiology is not well-understood. There is a critical need to advance objective biomarkers, allowing the identification and tracking of the long-term evolution of changes resulting from mTBI. Diffusion-weighted imaging (DWI) allows for the assessment of white-matter properties in the brain and shows promise as a suitable biomarker of mTBI pathophysiology. Methods: 34 individuals within a year of an mTBI (age: 24.4 ± 7.4) and 18 individuals with no history of mTBI (age: 23.2 ± 3.4) participated in this study. Participants completed self-report measures related to functional outcomes, psychological health, post-injury symptoms, and sleep, and underwent a neuroimaging session that included DWI. Whole-brain white matter was skeletonized using tract-based spatial statistics (TBSS) and compared between groups as well as correlated within-group with the self-report measures. Results: There were no statistically significant anatomical differences between the two groups. After controlling for time since injury, fractional anisotropy (FA) demonstrated a negative correlation with sleep quality scores (higher FA was associated with better sleep quality) and increasing depressive symptoms in the mTBI participants. Conversely, mean (MD) and radial diffusivity (RD) demonstrated positive correlations with sleep quality scores (higher RD was associated with worse sleep quality) and increasing depressive symptoms. These correlations were observed bilaterally in the internal capsule (anterior and posterior limbs), corona radiata (anterior and superior), fornix, and superior fronto-occipital fasciculi. Conclusion: The results of this study indicate that the clinical presentation of mTBI, particularly with respect to depression and sleep, is associated with reduced white-matter integrity in multiple areas of the brain, even after controlling for time since injury. These areas are generally associated not only with sleep and emotion regulation but also cognition. Consequently, the onset of depression and sleep dysfunction as well as cognitive impairments following mTBI may be closely related to each other and to white-matter integrity throughout the brain.

Epidemiology of mental health conditions in incoming division I collegiate athletes

OBJECTIVES

The purpose of this study is to examine the epidemiology of mental health conditions in incoming American Division I collegiate athletes.

METHODS

Pre-participation physical questionnaires from 1118 incoming student athletes at a Division I Institution were collected retrospectively from 2011-2017. Data collected included lifetime history of any mental health condition, musculoskeletal injuries, concussions, and post-concussion depression. History of any mental health condition was evaluated by gender and sport played. It was also evaluated in comparison to musculoskeletal injuries and concussions.

RESULTS

The lifetime prevalence of any mental health condition was 14.0% for all athletes, 14.2% for male athletes, and 13.6% for female athletes. Individual sports reported a greater prevalence (17.2%) than did team sports (11.8%) (p = 0.010). The prevalence was also higher in contact sports (16.4%) than in non-contact sports (12.5%), although this difference was not statistically significant (p = 0.072). There was a significant association between mental health condition and all four major groups of injuries examined: upper extremity (p = 0.043), lower extremity (p = 0.007), axial skeletal (p < 0.001), and concussions (p = 0.039). Post-concussion depression occurred in 2.0% of all athletes reporting a concussion.

CONCLUSION

The lifetime prevalence of mental health conditions in this population (14.0%) is far less than estimates in the general population. This observation may be due to a combination of factors including exercise/athletic participation mitigating depressive symptoms, competitive selection, and underreporting. History of a mental health condition may be associated with injury, although causation cannot be determined.

Pathophysiological Bases of Comorbidity: Traumatic Brain Injury and Post-Traumatic Stress Disorder

The high rates of traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) diagnoses encountered in recent years by the United States Veterans Affairs Healthcare System have increased public awareness and research investigation into these conditions. In this review, we analyze the neural mechanisms underlying the TBI/PTSD comorbidity. TBI and PTSD present with common neuropsychiatric symptoms including anxiety, irritability, insomnia, personality changes, and memory problems, and this overlap complicates diagnostic differentiation. Interestingly, both TBI and PTSD can be produced by overlapping pathophysiological changes that disrupt neural connections termed the "connectome." The neural disruptions shared by PTSD and TBI and the comorbid condition include asymmetrical white matter tract abnormalities and gray matter changes in the basolateral amygdala, hippocampus, and prefrontal cortex. These neural circuitry dysfunctions result in behavioral changes that include executive function and memory impairments, fear retention, fear extinction deficiencies, and other disturbances. Pathophysiological etiologies can be identified using experimental models of TBI, such as fluid percussion or blast injuries, and for PTSD, using models of fear conditioning, retention, and extinction. In both TBI and PTSD, there are discernible signs of neuroinflammation, excitotoxicity, and oxidative damage. These disturbances produce neuronal death and degeneration, axonal injury, and dendritic spine dysregulation and changes in neuronal morphology. In laboratory studies, various forms of pharmacological or psychological treatments are capable of reversing these detrimental processes and promoting axonal repair, dendritic remodeling, and neurocircuitry reorganization, resulting in behavioral and cognitive functional enhancements. Based on these mechanisms, novel neurorestorative therapeutics using anti-inflammatory, antioxidant, and anticonvulsant agents may promote better outcomes for comorbid TBI and PTSD.

Selective Serotonin Reuptake Inhibitors for Treating Neurocognitive and Neuropsychiatric Disorders Following Traumatic Brain Injury: An Evaluation of Current Evidence

The prevalence of neuropsychiatric disorders following traumatic brain injury (TBI) is 20%-50%, and disorders of mood and cognition may remain even after recovery of neurologic function is achieved. Selective serotonin reuptake inhibitors (SSRI) block the reuptake of serotonin in presynaptic cells to lead to increased serotonergic activity in the synaptic cleft, constituting first-line treatment for a variety of neurocognitive and neuropsychiatric disorders. This review investigates the utility of SSRIs in treating post-TBI disorders. In total, 37 unique reports were consolidated from the Cochrane Central Register and PubMed (eight randomized-controlled trials (RCTs), nine open-label studies, 11 case reports, nine review articles). SSRIs are associated with improvement of depressive but not cognitive symptoms. Pooled analysis using the Hamilton Depression Rating Scale demonstrate a significant mean decrease of depression severity following sertraline compared to placebo-a result supported by several other RCTs with similar endpoints. Evidence from smaller studies demonstrates mood improvement following SSRI administration with absent or negative effects on cognitive and functional recovery. Notably, studies on SSRI treatment effects for post-traumatic stress disorder after TBI remain absent, and this represents an important direction of future research. Furthermore, placebo-controlled studies with extended follow-up periods and concurrent biomarker, neuroimaging and behavioral data are necessary to delineate the attributable pharmacological effects of SSRIs in the TBI population.

Symptom profiles and illness course among Anabaptist and Non-Anabaptist adults with major mood disorders

Background

Anabaptists comprise large and growing Amish and Mennonite populations with a unique genetic heritage and cultural background. Little is known about the symptoms and course of major mood disorders in Anabaptists. Even less is known about the impact of potential moderators on symptom severity and course.

Methods

A sample of Amish and Mennonite participants with bipolar, recurrent unipolar, or schizoaffective bipolar disorder (n = 155) were systematically evaluated with a well-validated instrument. Cases were compared with non-Anabaptist participants (n = 155) matched for age, sex, and psychiatric diagnosis and evaluated by the same methods.

Results

Despite substantial cultural differences, the profile of manic and depressive symptoms during illness episodes did not significantly differ between the two groups. Alcohol use disorder (AUD) was significantly less frequent among Anabaptists, and was associated with more major depressive episodes and more hospitalizations for major depression in Anabaptist, but not non-Anabaptist participants. Lifetime history of head injury showed a trend toward association with more episodes of major depression in both Anabaptist and non-Anabaptist groups that did not withstand multiple test correction.

Conclusions

The presentation of a highly heritable psychiatric illness such as bipolar disorder does not differ in cases drawn from genetically unique Anabaptist populations. However, alcohol comorbidity, head injury, and their effects on illness course suggest some differences that deserve further investigation.

Disrupted White Matter Microstructure and Mood Disorders after Traumatic Brain Injury

Traumatic brain injury (TBI) is associated with an elevated frequency of mood disorders that may, in part, be explained by changes in white-matter microstructure. This study is the first to examine the relationship between mood disorders and white-matter pathology in a sample of patients with mild to severe TBI using a standardized psychiatric interview. This study reports on a sub-sample of 29 individuals recruited from a large prospective study that examined the evolution of psychiatric disorders following complicated, mild to severe TBI. Individuals with TBI were also compared with 23 healthy control participants. Individuals were invited to complete the Structured Clinical Interview for DSM-IV Disorders (SCID) to diagnose psychiatric disorders. Participants who developed a mood disorder within the first 3 years were categorized into a TBI-Mood group. Diffusion tensor tractography assessed white matter microstructure using atlas-based tract-averaged and along-tract approaches. Fractional anisotropy (FA) was used as the measure of white-matter microstructure. TBI participants with and without a mood disorder did not differ in regard to injury severity and other background factors. Nevertheless, TBI participants diagnosed with a mood disorder displayed significantly lower tract-averaged FA values for the right arcuate fasciculus (p = 0.011), right inferior longitudinal fasciculus (p = 0.009), and anterior segments I (p = 0.0004) and II (p = 0.007) of the corpus callosum, as well as the left (p = 0.014) and right (p = 0.015) fronto-occipital longitudinal fasciculi. The pattern of white matter disruption identified in the current study provides further support for a neurobiological basis of post-TBI mood disorders. Greater understanding of individuals' underlying neuropathology may enable better characterization and prediction of mood disorders. Integration of neuropathology may also inform the potential efficacy of pharmacological and psychological interventions.

Neurocognitive functioning in euthymic patients with bipolar disorder and unaffected relatives: A review of the literature

BACKGROUND

Neurocognitive deficits are present in bipolar disorder (BD) patients and their unaffected (nonbipolar) relatives, but it is not clear which domains are most often impaired and the extent of the impairment resulting from shared genetic factors. In this literature review, we address these issues and identify specific neurocognitive tasks most sensitive to cognitive deficits in patients and unaffected relatives.

METHOD

We conducted a systematic review in Web of Science, PubMed/Medline and PsycINFO databases.

RESULTS

Fifty-one articles assessing cognitive functioning in BD patients (23 studies) and unaffected relatives (28 studies) were examined. Patients and, less so, relatives show impairments in attention, processing speed, verbal learning/memory, and verbal fluency.

CONCLUSION

Studies were more likely to find impairment in patients than relatives, suggesting that some neurocognitive deficits may be a result of the illness itself and/or its treatment. However, small sample sizes, differences among relatives studied (e.g., relatedness, diagnostic status, age), and differences in assessment instruments may contribute to inconsistencies in reported neurocognitive performance among relatives. Additional studies addressing these issues are needed.

Mania secondary to focal brain lesions: implications for understanding the functional neuroanatomy of bipolar disorder

OBJECTIVES

Approximately 3.5 million Americans will experience a manic episode during their lifetimes. The most common causes are psychiatric illnesses such as bipolar I disorder and schizoaffective disorder, but mania can also occur secondary to neurological illnesses, brain injury, or neurosurgical procedures.

METHODS

For this narrative review, we searched Medline for articles on the association of mania with stroke, brain tumors, traumatic brain injury, multiple sclerosis, neurodegenerative disorders, epilepsy, and neurosurgical interventions. We discuss the epidemiology, features, and treatment of these cases. We also review the anatomy of the lesions, in light of what is known about the neurobiology of bipolar disorder.

RESULTS

The prevalence of mania in patients with brain lesions varies widely by condition, from <2% in stroke to 31% in basal ganglia calcification. Mania occurs most commonly with lesions affecting frontal, temporal, and subcortical limbic brain areas. Right-sided lesions causing hypo-functionality or disconnection (e.g., stroke; neoplasms) and left-sided excitatory lesions (e.g., epileptogenic foci) are frequently observed.

CONCLUSIONS

Secondary mania should be suspected in patients with neurological deficits, histories atypical for classic bipolar disorder, and first manic episodes after the age of 40 years. Treatment with antimanic medications, along with specific treatment for the underlying neurologic condition, is typically required. Typical lesion locations fit with current models of bipolar disorder, which implicate hyperactivity of left-hemisphere reward-processing brain areas and hypoactivity of bilateral prefrontal emotion-modulating regions. Lesion studies complement these models by suggesting that right-hemisphere limbic-brain hypoactivity, or a left/right imbalance, may be relevant to the pathophysiology of mania.

Life after Adolescent and Adult Moderate and Severe Traumatic Brain Injury: Self-Reported Executive, Emotional, and Behavioural Function 2-5 Years after Injury

Survivors of moderate-severe Traumatic Brain Injury (TBI) are at risk for long-term cognitive, emotional, and behavioural problems. This prospective cohort study investigated self-reported executive, emotional, and behavioural problems in the late chronic phase of moderate and severe TBI, if demographic characteristics (i.e., age, years of education), injury characteristics (Glasgow Coma Scale score, MRI findings such as traumatic axonal injury (TAI), or duration of posttraumatic amnesia), symptoms of depression, or neuropsychological variables in the first year after injury predicted long-term self-reported function. Self-reported executive, emotional, and behavioural functioning were assessed among individuals with moderate and severe TBI (N = 67, age range 15–65 years at time of injury) 2–5 years after TBI, compared to a healthy matched control group (N = 72). Results revealed significantly more attentional, emotional regulation, and psychological difficulties in the TBI group than controls. Demographic and early clinical variables were associated with poorer cognitive and emotional outcome. Fewer years of education and depressive symptoms predicted greater executive dysfunction. Younger age at injury predicted more aggressive and rule-breaking behaviour. TAI and depressive symptoms predicted Internalizing problems and greater executive dysfunction. In conclusion, age, education, TAI, and depression appear to elevate risk for poor long-term outcome, emphasising the need for long-term follow-up of patients presenting with risk factors.

Sleep disruption and the sequelae associated with traumatic brain injury

Sleep disruption, which includes a loss of sleep as well as poor quality fragmented sleep, frequently follows traumatic brain injury (TBI) impacting a large number of patients each year in the United States. Fragmented and/or disrupted sleep can worsen neuropsychiatric, behavioral, and physical symptoms of TBI. Additionally, sleep disruption impairs recovery and can lead to cognitive decline. The most common sleep disruption following TBI is insomnia, which is difficulty staying asleep. The consequences of disrupted sleep following injury range from deranged metabolomics and blood brain barrier compromise to altered neuroplasticity and degeneration. There are several theories for why sleep is necessary (e.g., glymphatic clearance and metabolic regulation) and these may help explain how sleep disruption contributes to degeneration within the brain. Experimental data indicate disrupted sleep allows hyperphosphorylated tau and amyloid β plaques to accumulate. As sleep disruption may act as a cellular stressor, target areas warranting further scientific investigation include the increase in endoplasmic reticulum and oxidative stress following acute periods of sleep deprivation. Potential treatment options for restoring the normal sleep cycle include melatonin derivatives and cognitive behavioral therapy.

Expert consensus document: Mind the gaps—advancing research into short-term and long-term neuropsychological outcomes of youth sports-related concussions

Sports-related concussions and repetitive subconcussive exposure are increasingly recognized as potential dangers to paediatric populations, but much remains unknown about the short-term and long-term consequences of these events, including potential cognitive impairment and risk of later-life dementia. This Expert Consensus Document is the result of a 1-day meeting convened by Safe Kids Worldwide, the Alzheimer's Drug Discovery Foundation, and the Andrews Institute for Orthopaedics and Sports Medicine. The goal is to highlight knowledge gaps and areas of critically needed research in the areas of concussion science, dementia, genetics, diagnostic and prognostic biomarkers, neuroimaging, sports injury surveillance, and information sharing. For each of these areas, we propose clear and achievable paths to improve the understanding, treatment and prevention of youth sports-related concussions.

Considerations for return to work following traumatic brain injury

Population-based studies have demonstrated that a history positive for traumatic brain injury (TBI) can result in cognitive impairment, behavioral alterations, and pain. These outcomes can and do influence occupational function, can affect others in the workplace, and raise concerns about workplace safety upon re-entry to the workplace. Risk for long-term impairment and disability can in some cases be mitigated by assessment of capabilities relative to job duties, conservative return-to-work schedules, and, in some cases, interventions to support that return. For those in occupations at high risk for brain injury, including first responders, soldiers, and construction workers, the long-term risk of brain injury as a risk factor for neurodegenerative disease must and should inform increased concern for those with repeated injuries to the brain over the course of their lifetime and career. This chapter reviews the risks of TBI, considers factors that optimize functional recovery, and discusses potential interventions and factors that aid in return to the workplace.

Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: insights into psychiatric practice

Traumatic brain injury (TBI) causes a variety of neuropsychiatric problems that pose diagnostic and treatment challenges for providers. In this report, we share our experience as a referral neuropsychiatry program to assist the general psychiatrist when adult TBI patients with psychiatric symptoms present for evaluation and treatment. We completed a retrospective study of patients with moderate-to-severe TBI and severe neuropsychiatric impairments. We collected information on demographics, nature of injury, symptomatology, diagnoses, and treatments. Data analysis indicates that mood stabilization was a key concern, often requiring aggressive pharmacological management. Cognitive dysfunction was a problem for the majority of patients, but was only medicated in a third, due to poor efficacy or behavioral side effects. The co-occurrence of multiple TBI-related symptoms and diagnoses in this patient cohort emphasizes the need for individualized psychopharmacological approaches and interventions.

Counseling athletes on the risk of chronic traumatic encephalopathy

Context:

Chronic traumatic encephalopathy (CTE) is a rare progressive neurologic disorder that can manifest as a combination of cognitive, mood and behavioral, and neurologic symptoms. Despite clinically apparent symptoms, there is no imaging or other diagnostic test that can confirm diagnosis in living subjects. Diagnosis can only be confirmed postmortem by specific histopathologic features within the brain tissue identified on autopsy. CTE represents a unique tauopathy that is distinct from other neurodegenerative diseases.

Evidence Acquisition:

PubMed was searched from 1990 to 2013 for sport concussion and chronic traumatic encephalopathy. Articles were also identified from bibliographies of recent reviews and consensus statements.

Study Design:

Clinical review.

Level of Evidence:

Level 5.

Results:

Although CTE is postulated to occur as a result of repetitive mild traumatic brain injury, the specific etiology and risk factors have not yet been elucidated, and postmortem diagnosis makes causality difficult to determine.

Conclusion:

When counseling athletes and families about the potential association of recurrent concussions and the development of CTE, discussion of proper management of concussion is cornerstone. Unfortunately, to date, there is no equipment that can prevent concussions; however, rule changes and legislation may decrease the risk. It is imperative that return to play is medically supervised by a provider trained in the management of concussion and begins only once symptoms have resolved. In addition, athletes with permanent symptoms should be retired from contact sport.

Deficits in discrimination after experimental frontal brain injury are mediated by motivation and can be improved by nicotinamide administration

One of the largest challenges in experimental neurotrauma work is the development of models relevant to the human condition. This includes both creating similar pathophysiology as well as the generation of relevant behavioral deficits. Recent studies have shown that there is a large potential for the use of discrimination tasks in rats to detect injury-induced deficits. The literature on discrimination and TBI is still limited, however. The current study investigated motivational and motor factors that could potentially contribute to deficits in discrimination. In addition, the efficacy of a neuroprotective agent, nicotinamide, was assessed. Rats were trained on a discrimination task and motivation task, given a bilateral frontal controlled cortical impact TBI (+3.0 AP, 0.0 ML from bregma), and then reassessed. They were also assessed on motor ability and Morris water maze (MWM) performance. Experiment 1 showed that TBI resulted in large deficits in discrimination and motivation. No deficits were observed on gross motor measures; however, the vehicle group showed impairments in fine motor control. Both injured groups were impaired on the reference memory MWM, but only nicotinamide-treated rats were impaired on the working memory MWM. Nicotinamide administration improved performance on discrimination and motivation measures. Experiment 2 evaluated retraining on the discrimination task and suggested that motivation may be a large factor underlying discrimination deficits. Retrained rats improved considerably on the discrimination task. The tasks evaluated in this study demonstrate robust deficits and may improve the detection of pharmaceutical effects by being very sensitive to pervasive cognitive deficits that occur after frontal TBI.

A rare mutation of CACNA1C in a patient with bipolar disorder, and decreased gene expression associated with a bipolar-associated common SNP of CACNA1C in brain

Timothy Syndrome (TS) is caused by very rare exonic mutations of the CACNA1C gene that produce delayed inactivation of Cav1.2 voltage-gated calcium channels during cellular action potentials, with greatly increased influx of calcium into the activated cells. The major clinical feature of this syndrome is a long QT interval that results in cardiac arrhythmias. However, TS also includes cognitive impairment, autism and major developmental delays in many of the patients. We observed the appearance of bipolar disorder (BD) in a patient with a previously reported case of TS, who is one of the very few patients to survive childhood. This is most interesting because the common single-nucleotide polymorphism (SNP) most highly associated with BD is rs1006737, which we show here is a cis-expression quantitative trait locus for CACNA1C in human cerebellum, and the risk allele (A) is associated with decreased expression. To combine the CACNA1C perturbations in the presence of BD in this patient and in patients with the common CACNA1C SNP risk allele, we would propose that either increase or decrease in calcium influx in excitable cells can be associated with BD. In treatment of BD with calcium channel blocking drugs, we would predict better response in patients without the risk allele, because they have increased CACNA1C expression.

Mood disorders after TBI

In this article, we examine the epidemiology and risk factors for the development of the most common mood disorders observed in the aftermath of TBI: depressive disorders and bipolar spectrum disorders. We describe the classification approach and diagnostic criteria proposed in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders. We also examine the differential diagnosis of post-TBI mood disorders and describe the mainstay of the evaluation process. Finally, we place a special emphasis on the analysis of the different therapeutic options and provide guidelines for the appropriate management of these conditions.

Patient Characterization Protocols for Psychophysiological Studies of Traumatic Brain Injury and Post-TBI Psychiatric Disorders

Psychophysiological investigations of traumatic brain injury (TBI) are being conducted for several reasons, including the objective of learning more about the underlying physiological mechanisms of the pathological processes that can be initiated by a head injury. Additional goals include the development of objective physiologically based measures that can be used to monitor the response to treatment and to identify minimally symptomatic individuals who are at risk of delayed-onset neuropsychiatric disorders following injury. Research programs studying TBI search for relationships between psychophysiological measures, particularly ERP (event-related potential) component properties (e.g., timing, amplitude, scalp distribution), and a participant's clinical condition. Moreover, the complex relationships between brain injury and psychiatric disorders are receiving increased research attention, and ERP technologies are making contributions to this effort. This review has two objectives supporting such research efforts. The first is to review evidence indicating that TBI is a significant risk factor for post-injury neuropsychiatric disorders. The second objective is to introduce ERP researchers who are not familiar with neuropsychiatric assessment to the instruments that are available for characterizing TBI, post-concussion syndrome, and psychiatric disorders. Specific recommendations within this very large literature are made. We have proceeded on the assumption that, as is typically the case in an ERP laboratory, the investigators are not clinically qualified and that they will not have access to participant medical records.

Managing behavioral health needs of veterans with traumatic brain injury (TBI) in primary care

Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20 % among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.

The temporal relationship between depression, anxiety, and functional status after traumatic brain injury: a cross-lagged analysis

Poor functional status and high rates of anxiety and depression have been reported in individuals who have sustained a traumatic brain injury (TBI). However, it is unclear whether psychiatric disorders after TBI are a cause or a consequence of functional limitations. The current study aimed to investigate the temporal relationship between anxiety, depression and functional impairment following TBI. The study has a prospective, longitudinal single-group design. Anxiety and depression, assessed using the Structured Clinical Interview for DSM-IV, and functional changes, assessed with the Glasgow Outcome Scale-Extended, were measured six and 12 months post-injury in 122 individuals who had sustained a TBI (79% male, mean age 35 years, mean duration of post-traumatic amnesia 24 days, mean Glasgow Coma Scale score 9.2). Cross-lagged analyses were conducted within a structural equation modelling framework. Functional changes six months post-injury predicted depression and anxiety one year after the injury. Anxiety and depression, in turn, were not predictive of later functional status. This study adds to our understanding of the temporal relationship between depression, anxiety and functional status after TBI. The results indicate the importance of supporting brain injured individuals in coping with the functional consequences of their injury in order promote psychological well-being.

The relationship between mood disorders and MRI findings following traumatic brain injury

BACKGROUND

High rates of depression have been reported in individuals with traumatic brain injury (TBI). The purpose of the current study was to investigate the relationship between structural MRI findings and the development of novel cases of post-injury depression in this population

METHODS

The study has a cross-sectional design. Assessments were conducted on average 2.2 years post-injury. Participants were 54 individuals (76% male, mean age 35 years, median PTA duration 16 days) who had sustained a TBI. Depression was assessed with the Structured Clinical Interview for DSM-IV (SCID-IV). Structural MRI scans were performed with a 1.5 Tesla machine.

RESULTS

The presence of lesions in the frontal, temporal, parietal and the sublobar regions was not related to depression. However, an imbalance of left vs right frontal and parietal viable brain volumes was related to the development of depression.

DISCUSSION

These findings are in support of Heller's model of emotion processing, but should be replicated using larger samples. Potential clinical implications are discussed in the manuscript.

Predictors of psychiatric disorders following traumatic brain injury

OBJECTIVE

To investigate predictors of posttraumatic brain injury psychiatric disorders.

DESIGN

Retrospective, cross-sectional design with stratified random sampling of groups of patients on average 1 to 5 years postinjury. DSM-based diagnostic interviews of both traumatic brain injury (TBI) participant and informant.

PARTICIPANTS

One hundred community-based participants, aged 19-74 years, with traumatic brain injury sustained 0.05-5.5 years previously.

SETTING

Community-based patients previously treated at a rehabilitation hospital.

MAIN MEASURE

The Structured Clinical Interview for DSM-IV diagnosis.

RESULTS

A psychiatric history was a high-risk factor for having the same disorder postinjury. However, the majority of cases of depression and anxiety were novel, suggesting that significant factors other than pre-TBI psychiatric status contribute to post-TBI psychiatric outcome. Female gender, lower education, and pain were also associated with postinjury depression and unemployment and older age with anxiety.

CONCLUSION

Findings suggest that long-term screening and support are important for individuals with TBI, regardless of preinjury psychiatric status.

The factor structure of the Hospital Anxiety and Depression Scale in individuals with traumatic brain injury

There is a lack of validated scales for screening for anxiety and depression in individuals with traumatic brain injury (TBI). The purpose of this study was to examine the factor structure of the Hospital Anxiety and Depression Scale (HADS) in individuals with TBI. A total of 294 individuals with TBI (72.1% male; mean age 37.1 years, S.D. 17.5, median post-traumatic amnesia (PTA) duration 17 days) completed the HADS 1 year post-injury. A series of confirmatory factor analyses was conducted to examine the fit of a one-, two- and three-factor solution, with and without controlling for item wording effects (Multi-Trait Multi-Method approach). The one-, two- or three-factor model fit the data only when controlling for negative item wording. The results are in support of the validity of the original anxiety and depression subscales of the HADS and demonstrate the importance of evaluating item wording effects when examining the factor structure of a questionnaire. The results would also justify the use of the HADS as a single scale of emotional distress. However, even though the three-factor solution fit the data, alternative scales should be used if the purpose of the assessment is to measure stress symptoms separately from anxiety and depression.

Ethical perspectives on relations between industry and neuropsychiatric medicine

Conflicts of interest may influence medical research. In particular, the study on psychotropic treatment of ageing subjects suffering from neurological disorders and comorbid neuropsychiatric phenomena may be hypothetically considered economically non-advantageous, or even of negative impact on drug reputation, because of the high probability of non-response or side effects. Thus, studies on this issue may be disregarded from industry. We aimed to verify whether the global commitment of medical research reflects the actual relevance of depression in the world ageing population, associated or not with neurological conditions. Here, we: 1) have reviewed the literature on this issue, 2) have examined world published data concerning population by age, burden of disease and frequency of depressive disorders and antidepressant therapies, and 3) have reviewed the frequency of published papers on depression and its treatment associated with three neurological conditions. The overall rate of papers about depressive disorders in ageing people reflects adequately the world population and the prevalence of depression in the elderly. However, the rate of papers concerning medical experimentation for antidepressant treatment in Alzheimer's disease, Parkinson's disease and stroke is quite inadequate with respect to the rate of depressive disorders associated to these conditions. Thus, innovative medical experimentation must be encouraged, also in areas apparently of dubious economical advantage but of undoubted clinical relevance and the adoption of strategies to limit the detrimental effect of conflicts of interest in research must be enhanced.

Hope, dispositional optimism and severity of depression following traumatic brain injury

PRIMARY OBJECTIVE

To investigate the extent in which two coping variables-hope and dispositional optimism-are related to depression severity amongst individuals who have sustained traumatic brain injury (TBI).

METHODS AND PROCEDURES

Sixty-five participants were administered the Beck Depression Inventory (BDI), the Adult Hope Scale (AHS), the Life Orientation Test-Revised (LOT-R) and a demographic and injury-related data questionnaire. In addition, relevant injury-related data was collected from the medical records.

MAIN OUTCOMES AND RESULTS

High levels of depression were experienced in the study sample, while hope and dispositional optimism were significantly lower in comparison to the general population. The correlation patterns indicate that both hope and dispositional optimism negatively correlated with participants' depression levels and that they showed significant positive correlations with each other. In the case of mild depression, the hope-Pathways sub-scale of the AHS was the only variable negatively correlated to it, while in moderate-to-severe depression all coping variables were negatively correlated to it. Regression analysis revealed that the AHS and LOT-R, but not the demographic and injury-related variables, predicted depression severity.

CONCLUSIONS

Clinical implications in referring persons with TBI with mild vs. severe depression to rehabilitation programmes are discussed.